Homegrown paediatric care in Africa

Three years ago, newly qualified paediatrician Dr Kondwani Kwazi returned home to Malawi and implemented two low-cost, life-saving ideas at the neonatal unit in the hospital where he worked.

A "graduate" of UCT's African Paediatric Fellowship Programme (APFP), Kwazi instituted kangaroo care '“ prolonged skin-to-skin contact between mothers and their premature babies, a method pioneered in Colombia and now used widely to support infants at risk. He also introduced "bubble CPAP", innovative breathing support for newborns using a simple tank of water and a pair of aquarium pumps to control the air pressure delivered to the baby.

The interventions were cheap and effective; important words in one of Africa's poorest nations, with its mortality rate of 71 per 1 000 live births for children under five, according to World Bank 2012 statistics.

In low-income countries worldwide, children are 16 times more likely to die before their fifth birthday; 75% of these deaths are due to avoidable diseases such as pneumonia, diarrhoea, malaria and measles.

Kwazi is one of 44 APFP fellows from 23 medical centres in 11 sub-Saharan African countries who have benefited from the training programme. The programme boosts their surgical and general paediatric skills '“ and helps them think on their feet in resource-poor settings. Right now, there are 22 fellows in the pipeline.

Reverse the exodus

Stories like Kwazi's were key to Professor Jo Wilmshurst's 30 July inaugural lecture title: Reversing the Brain Drain.

Just the day before, SABC News quoted the Union for International Cancer Control's Riccardo Lampariello, who said that Africa had been hardest hit by the worldwide shortage of healthcare workers. Africa has 3% of the world's healthcare workers, but 24% of the global disease burden.

African governments are well aware of the problem, said Wilmshurst, but unable to staunch the flow.

African doctors sent abroad to specialise usually don't come back. In 2000, Malawi had eight paediatricians for a population of over 15 million, but most were due to retire. Concerned, the government sent 18 doctors to the UK to train as paediatricians. Only one of the two who returned stayed on.

In contrast, 98% of APFP fellows go home to plough their skills back into their communities, says Wilmshurst. (That's over five years; the one-year rate is 100%.)

The APFP was established in 2008, after a request to formalise the training UCT provided. Wilmshurst, head of paediatric neurology at the Red Cross War Memorial Children's Hospital and UCT's Department of Paediatrics and Child Health, has been director since 2009. She believes this growing network of Africa-trained paediatricians is creating a new wave of specialist care and capacity '“ and new energy to lobby for service provision, training, education and research.

Epilepsy as a microcosm

As a paediatric neurologist, epilepsy takes centre stage for Wilmshurst '“ and it provides a good mirror for the kinds of problems doctors grapple with in Africa, where even standard levels of care are rare, and where HIV absorbs most resources.

Epilepsy is the fourth most common neurological disorder worldwide, affecting 80 million people, according to the World Health Organisation (WHO).

At Red Cross, Wilmshurst and her team run 80 neurology clinics each month. Sixty percent of their patients have epilepsy.

"Epilepsy can be notoriously hard to diagnose, and affects every child differently. In some ways, being a paediatric neurologist is one of the ultimate detective jobs."

Without adequate resources, nine out of 10 Africans with epilepsy go undiagnosed and untreated '“ this on a continent where there's huge cultural stigma attached to epilepsy.

"We deal with everything here," said Wilmshurst, referring to her unit and the ripple effect of epilepsy. "They [the families] often have nowhere else to go. These children need special support, and have special needs. The burden on families is huge. We have to manage the child and their family holistically."

She and her team have spearheaded several workshops in Africa, to strategically understand what occurs at the coalface and tease out key themes and rallying points. The first workshop, in Uganda, was held under the auspices of the International Child Neurology Association, and attended by representatives from 34 African countries. High among the priorities was the need for national guidelines for treating epilepsy.

"Only nine of the countries had guidelines; but when we delved deeper, we found they couldn't deliver the level of care required by the guidelines. We need to be innovative about how we can work with the resources and facilities available."

Adapt and acclimatise

A case in point is oral pheno-barbital, which is widely prescribed. It's an extremely effective anti-epileptic drug, and essential to have available for emergency management of prolonged seizures.

"But it's rarely used in settings other than ours. It's particularly utilised in resource-poor countries, because it's cheap; and as such, more likely to be available. The limited usage in resource-equipped settings relates to concerns of learning and behavioural side effects reported to occur in children on the drug."

Wilmshurst advocates that Africans should tap into resources that are specific to Africa, such as traditional healers.

"They have fantastic observation skills, which have been effectively incorporated into healthcare programmes in Kenya, Cameroon and Uganda for early identification and referral of patients for treatment interventions."

She also advocates that local clinicians adapt international trends and health guidelines to make these relevant to Africa. And she believes Africans should lobby big international groups such as the WHO to make themselves heard.

What did emerge from the workshops was a common call: "Empower us to move forward to better care. Give us more skilled personnel and we will change this backdrop, working in our own settings to change these discrepancies in health care."

Wilmshurst is working with the International League Against Epilepsy, through the Paediatric Commission, to develop international guidelines for use at local level, with pilot studies in Kenya, South America and India scheduled.

The right stuff

As for the brain drain, training specialists in Africa does lead to better retention of the trainees when they return home.

"It means the training we give them is more relevant, and empowers them to cope better. The collaboration with the doctors we've worked with and trained has been phenomenal."

The circle has been enlarged to include nurses and allied personnel, under the leadership of Minette Coetzee and Brenda Morrow respectively.

"The APFP is developing hubs of expertise that will trickle all the way down from tertiary to primary care," said Wilmshurst.

Listen to the audio recording of Prof Wilmshurst's lecture (40.5 mb)